Trachoma elimination targets missed in Australia
Authors: Rebecca Barksby
Journal: The Lancet Microbe (2022)

On Aug 22, 2022, Togo confirmed that the country had eliminated four neglected tropical diseases (NTDs), the first country to do so. The announcement came after trachoma was declared the latest NTD to be eliminated in Togo. Trachoma—an eye disease caused by the bacterium Chlamydia trachomatis—is the leading infectious cause of blindness worldwide, mainly affecting children in rural communities who do not have access to safe water for face and hand washing. Approximately 90% of cases are from Africa, but Togo is not the only African country to successfully control trachoma, with Morocco (2016), Ghana (2018), Gambia (2021), and Malawi (2022) achieving elimination in recent years. With the past successes in eliminating trachoma in low-resource settings, and its association with poor sanitation, it is surprising that trachoma is still present in Australia, the only high-income country where the disease still exists. Australia committed to eliminate trachoma as part of the WHO Global Alliance for the Elimination of Trachoma by the year 2020. The country did have some success, with the national trachoma prevalence rate in children aged 5–9 years decreasing from 14% in 2009 to 3·3% in 2021; however, the target of elimination by 2020, and the subsequent target for 2022, were ultimately not met. “We need to do far better to meet all conditions for elimination, with endemic levels still existing in some regions,” said a representative from the Australian Government Department of Health and Aged Care (Canberra, ACT, Australia). These regions are primarily remote Indigenous communities in South Australia, Western Australia, and the Northern Territory, with 115 communities identified as being at risk. In April 2020, WHO recommended suspension of mass treatment, screening, and surveys for NTDs because of the COVID-19 pandemic. This suspension affected trachoma programmes worldwide, including in Australia, with the government representative telling The Lancet Microbe that the pandemic “affected trachoma screening and treatment activities in First Nations communities” due to “travel restrictions and the diversion of clinical staff to the COVID-19 public health response”. COVID-19 caused understandable disruption to trachoma control; however, the disease was present in Australia for many years prior to the pandemic. A reason why trachoma has been persisting in Australia is because of the remote location and inequities of the communities it affects. In December 2021, the Australian Government published the National Aboriginal and Torres Strait Islander Health Plan 2021–2031 (Health Plan), which The Lancet Microbe was told: “prioritises the social determinants of health and provides a platform for implementation of cross-jurisdictional action focused on the underlying conditions that give rise to trachoma”. This acknowledgment of the social determinants of trachoma is important. Sightsavers—a non-governmental organisation that works in low-income and middle-income countries to treat and prevent trachoma—has helped several countries eliminate trachoma. Their success has shown that the WHO-endorsed four-part strategy (surgery to treat blinding trichiasis, antibiotics to clear infection, promotion of facial cleanliness, and improving access to water and sanitation) works, but the director of NTDs Simon Bush (Sightsavers, Accra, Ghana) emphasises that understanding social context is crucial. “We can't underestimate the influence of the community volunteers who go out into their villages and win people's trust in [trachoma] treatments”, he told The Lancet Microbe. Culturally informed interventions are outlined as a priority in the Health Plan and the Australian Government representative said that they are working closely with the National Aboriginal Community-Controlled Health Organisation “to explore what role it and its members could play in both the design and implementation of responses to trachoma”. The recognition that local communities need to be involved in trachoma interventions is a step forward to eliminating the disease from Australia, but it also emphasises how these communities have been neglected for years. The health disparities between Indigenous and non-Indigenous communities in Australia are well documented in the Overcoming Indigenous Disadvantage reports, which the Australian Government have commissioned since 2002. The latest report stated that hospitalisation rates for Indigenous people with diseases that are associated with poor environmental health are more than double those of non-Indigenous people, and they are also 1·5-times more likely to die from such a disease. Data on access to safe water and sewerage systems for these communities has not been available since 2006, but the report states that, in 2018–19, one in five Indigenous households lived in housing of an “unacceptable standard”, suggesting that water and washing facilities may also be inadequate to prevent health conditions. Trachoma prevalence in Australia has declined over the past decade and the government has made commitments to improving the health of Indigenous people. However, achieving the last step of elimination will be difficult if data on living conditions are not recorded or improved. In the words of Simon Bush: “trachoma elimination requires leaving no one behind”. For more on Togo eliminating four NTDs see https://www.who.int/news/item/22-08-2022-who-director-general-congratulates-togo-on-becoming-first-country-to-eliminate-four-neglected-tropical-diseasesFor the Australian Trachoma Surveillance Report 2019 see https://kirby.unsw.edu.au/report/australian-trachoma-surveillance-report-2019For more on trachoma in Australia see https://www.health.gov.au/initiatives-and-programs/addressing-trachomaFor the National Aboriginal and Torres Strait Islander Health Plan 2021–2031 see https://www.health.gov.au/resources/publications/national-aboriginal-and-torres-strait-islander-health-plan-2021-2031For Sightsavers work on trachoma https://www.sightsavers.org/protecting-sight/ntds/what-is-trachoma/For the Organisation for Economic Co-operation and Development report see https://www.oecd-ilibrary.org/sites/ab4d8d52-en/index.html?itemId=/content/publication/ab4d8d52-enFor the 2020 Overcoming Indigenous Disadvantage report see https://www.pc.gov.au/ongoing/overcoming-indigenous-disadvantage/2020 For more on Togo eliminating four NTDs see https://www.who.int/news/item/22-08-2022-who-director-general-congratulates-togo-on-becoming-first-country-to-eliminate-four-neglected-tropical-diseases For the Australian Trachoma Surveillance Report 2019 see https://kirby.unsw.edu.au/report/australian-trachoma-surveillance-report-2019 For more on trachoma in Australia see https://www.health.gov.au/initiatives-and-programs/addressing-trachoma For the National Aboriginal and Torres Strait Islander Health Plan 2021–2031 see https://www.health.gov.au/resources/publications/national-aboriginal-and-torres-strait-islander-health-plan-2021-2031 For Sightsavers work on trachoma https://www.sightsavers.org/protecting-sight/ntds/what-is-trachoma/ For the Organisation for Economic Co-operation and Development report see https://www.oecd-ilibrary.org/sites/ab4d8d52-en/index.html?itemId=/content/publication/ab4d8d52-en For the 2020 Overcoming Indigenous Disadvantage report see https://www.pc.gov.au/ongoing/overcoming-indigenous-disadvantage/2020